HEAT-RELATED ILLNESS WORKSHEET - Missouri
| |Reporting Agency Name and Telephone |
|HEAT-RELATED ILLNESS WORKSHEET | |
|Patient First Name and Last Name |DOB Race Sex Ethnicity |
| | |
|Residence Street Address |Date of Illness Week |
| | |
|Residence City, State ZIP |Location where became ill (home, work, school - include address) |
| | |
|County |City State Zip |
| | |
|Physician |Diagnosis |
| | |
|Physician’s Address |Physician’s Phone Number |
| | |
|Hospitalized? Date Hospitalized |Died? Date of Death |
|Y N |Y N |
|Hospital Name |Hospital Address |
| | |
|Pre-existing Aggravating Medical Factors |
| |
|Contributing Activity (Working, Physical Exertion, Substance Use/Abuse, Recreational Activity, Sports, |Air Conditioning Available In Use |
|Other - explain) |Y N Y N |
| | |
| |Reporting Agency Name and Telephone |
|HEAT-RELATED ILLNESS WORKSHEET | |
|Patient First Name and Last Name |DOB Race Sex Ethnicity |
| | |
|Residence Street Address |Date of Illness Week |
| | |
|Residence City, State ZIP |Location where became ill (home, work, school - include address) |
| | |
|County |City State Zip |
| | |
|Physician |Diagnosis |
| | |
|Physician’s Address |Physician’s Phone Number |
| | |
|Hospitalized? Date Hospitalized |Died? Date of Death |
|Y N |Y N |
|Hospital Name |Hospital Location |
| | |
|Pre-existing Aggravating Medical Factors |
| |
|Contributing Activity (Working, Physical Exertion, Substance Use/Abuse, Recreational Activity, Other – |Air Conditioning Available In Use |
|explain) |Y N Y N |
| | |
Contact the Bureau of Environmental Epidemiology, Hyperthermia Prevention staff, at (866) 628-9891 for more information. Please fax completed forms to 573-526-6946. Rev. 07/02/2015
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